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Name

Gender

Age

Date of Visit

Counselor

Please answer the following questions using this scale:
1 - Not at all    2 - Somewhat    3 - Yes    4 - Very much     N/A - Not Applicable

Was today's session helpful?

1  

2  

3  

4  

N/A  

Did the counselor / doctor treat you with respect?

1  

2  

3  

4  

N/A  

Did the office staff treat you with respect?

1  

2  

3  

4  

N/A  

Was your assessment fair?

1  

2  

3  

4  

N/A  

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